Publications by authors named "Peter Hibbert"

81 Publications

Identifying safe care processes when GPs work in or alongside emergency departments: realist evaluation.

Br J Gen Pract 2021 May 27. Epub 2021 May 27.

Cardiff University School of Medicine, Cardiff, United Kingdom.

Background: Increasing pressure on emergency services has led to the development of different models of care delivery including GPs working in or alongside emergency departments (EDs), but with a lack of evidence for patient safety outcomes.

Aim: We aimed to explore how care processes work and how patient safety incidents associated with GPs working in ED settings may be mitigated.

Design And Setting: We used realist methodology with a purposive sample of 13 EDs with different GP service models. We sought to understand the relationship between contexts, mechanisms and outcomes to develop theories about how and why patient safety incidents may occur, and how safe care was perceived to be delivered.

Method: We collected qualitative data (observations, semi-structured audio-recorded staff interviews and local patient safety incident reports). We coded data using 'if, then, because' statements to refine initial theories developed from an earlier rapid realist literature review and analysis of a sample of national patient safety incident reports.

Results: We developed a programme theory to describe how safe patient care was perceived to be delivered in these service models including: an experienced streaming nurse using local guidance and early warning scores; support for GPs' clinical decision-making with clear governance processes relevant to the intended role (traditional GP approach or emergency medicine approach); and strong clinical leadership to promote teamwork and improve communication between services.

Conclusion: Our findings can be used as a focus for more in-depth human factors investigations to optimise work conditions in this complex care delivery setting.
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http://dx.doi.org/10.3399/BJGP.2021.0090DOI Listing
May 2021

Implementing high value back pain care in private physiotherapy in Australia: A qualitative evaluation of physiotherapists who participated in an "implementation to innovation" system.

Can J Pain 2020 May 18;4(1):86-102. Epub 2020 May 18.

IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia.

: Many barriers exist to delivering high-value care for people with low back pain (LBP). We have developed a multistrategy implementation system to overcome these barriers. Here we describe a qualitative evaluation of the experiences of private-sector physiotherapists implementing the system. : PRISM (Practice-based innovation and implementation system) is an iterative clinician-as-scientist implementation program, tailored here for acute and subacute LBP. PRISM integrates strategies from behavioral change, implementation, and educational science fields. Semistructured interviews, group discussion forums, and electronic questionnaires were used to collect data at multiple time points that were then analyzed using an interpretative descriptive approach. : Six physiotherapists (purposive sample) practicing in private practice physiotherapy clinics in the Adelaide region, South Australia, were enrolled in the study. : Interventions included an educational pain science and care workshop incorporating self-regulated learning principles, a co-planned clinical pathway, an electronic decision support tool, development and support of a community of practice, case study simulations, audit and feedback, and collaborative problem solving and innovation for physiotherapists. : Participants' experiences and perceptions centered around five themes: (1) knowledge and skills training; (2) networking and mentoring; (3) a clear clinical pathway; (4) practical tools; and (5) data feedback. Participants appraised the implementation process positively but identified patient receptiveness as a challenge at times. Suggestions for improvement included streamlining/automating data collection forms and processes and providing more simulation opportunities. : PRISM appears to be a promising approach to overcoming several barriers that prevent people with back pain from receiving high-value care. It consolidates and increases pain science knowledge and increases physiotherapist confidence in delivering high-value care. It appears to legitimize some current practices, enhance clinical reasoning and communication skills, extend knowledge in line with contemporary pain science, and facilitate the application of a biopsychosocial management approach. The high-level acceptance by participants provides a foundation for further research to test outcomes and delivery in different settings. A quality improvement intervention designed to improve delivery of high-value care was well received by private practice physiotherapists.Physiotherapists particularly valued using experiential learning to improve fluency in communicating with, and educating patients about, contemporary pain science.A structured clinical pathway and tools guided physiotherapists on the basic elements of necessary care and allowed them to concentrate on higher levels of decision making and communication with patients.
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http://dx.doi.org/10.1080/24740527.2020.1732808DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7951159PMC
May 2020

A classification of primary care streaming pathways in UK emergency departments: Findings from a multi-methods study comprising cross-sectional survey; site visits with observations, semi-structured and informal interviews.

Int Emerg Nurs 2021 May 17;56:101000. Epub 2021 Apr 17.

Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK.

Background: Variation in initial assessment methods at emergency departments in with primary care service models and a conflated terminology causes difficulties in assessing relative performance, improving quality or gathering evidence about safety and clinical effectiveness. We aim to describe and classify streaming pathways in emergency departments in different models of emergency department primary care services in England and Wales.

Methods: We used a multi-stage method, including an online survey completed by 77 emergency departments across England & Wales, interviews with 21 clinical leads, and in-depth case studies of 13 emergency departments. All qualitative data were triangulated and analysed using a framework approach.

Results: Common emergency department pathways to primary care services were: front door streaming; streaming inside the emergency department; or primary care staff selecting patients. Pathways were also in place to redirect patients with non-urgent primary care problems to community primary care services. Streaming and redirection pathways were often adapted, with variation in protocols based on local circumstances.

Conclusion: Clinical leads should consider which pathway(s) best suit their local context. Consistency of terminology used to describe pathways between emergency departments and primary care services is necessary for performance measurement, quality improvement and rigorous future multi-site evaluative and descriptive research.
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http://dx.doi.org/10.1016/j.ienj.2021.101000DOI Listing
May 2021

Assessing the appropriateness of the management of gastro-oesophageal reflux in Australian children: a population-based sample survey.

Sci Rep 2021 Apr 8;11(1):7744. Epub 2021 Apr 8.

Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia.

Gastro-oesophageal reflux (GOR) is a common physiological state in infants and young children, with gastro-oesophageal reflux disease (GORD) its pathological manifestation. Management of GOR/GORD requires elimination of possible underlying causes, parental reassurance, modification of feeding and symptom mitigation, monitoring, and referral to paediatricians if warning signs are present. Published clinical practice guidelines (CPGs) seek to support clinicians and improve management. This study aimed to measure the proportion of Australian GOR/GORD paediatric care that was in line with CPG recommendations. National and international CPGs for GOR/GORD were systematically identified and candidate indicators extracted; a Delphi process selected 32 indicators relevant to Australian paediatric care in 2012 and 2013. Medical records were identified in General Practices, the offices of general paediatricians, Emergency Departments and inpatient settings. Adherence to indicators was assessed by nine trained paediatric nurses undertaking retrospective medical record review. Medical records were reviewed in 115 healthcare sites; identifying 285 children, three-quarters aged < 1 year, who had 359 visits for management of GOR/GORD; 2250 eligible indicator assessments were performed. Estimated adherence rates are reported for 21 indicators with ≥ 25 assessments. Five indicators recommending differential diagnostic tests (e.g., urinalysis) for infants presenting with recurrent regurgitation and poor weight gain had ~ 10% adherence; conversely, avoidance of unrecommended tests (e.g., barium swallow and meal) was high (99.8% adherence: 95% CI 97.0-100). Avoidance of prescription of acid-suppression medication for infants at the first presentation was higher if they were healthy and thriving (86.9% adherence: 95% CI 86.0-96.8), intermediate if they had feeding refusal (73.1%: 95% CI 56.0-86.3) and lower if they presented with irritability and unexplained crying (58.8%: 95% CI 28.2-85.0). A guideline targeting Australian health professionals caring for infants and children with GOR/GORD is warranted, highlighting the importance of differential diagnostic testing and avoidance of acid-suppression medication in infants.
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http://dx.doi.org/10.1038/s41598-021-87369-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032666PMC
April 2021

Guideline adherence in the management of attention deficit hyperactivity disorder in children: An audit of selected medical records in three Australian states.

PLoS One 2021 8;16(2):e0245916. Epub 2021 Feb 8.

Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.

Objective: To assess General Practitioner (GP) and pediatrician adherence to clinical practice guidelines (CPGs) for diagnosis, treatment and management of attention deficit hyperactivity disorder (ADHD).

Method: Medical records for 306 children aged ≤15 years from 46 GP clinics and 20 pediatric practices in Australia were reviewed against 34 indicators derived from CPG recommendations. At indicator level, adherence was estimated as the percentage of indicators with 'Yes' or 'No' responses for adherence, which were scored 'Yes'. This was done separately for GPs, pediatricians and overall; and weighted to adjust for sampling processes.

Results: Adherence with guidelines was high at 83.6% (95% CI: 77.7-88.5) with pediatricians (90.1%; 95% CI: 73.0-98.1) higher than GPs (68.3%; 95% CI: 46.0-85.8; p = 0.02). Appropriate assessment for children presenting with signs or symptoms of ADHD was undertaken with 95.2% adherence (95% CI: 76.6-99.9), however ongoing reviews for children with ADHD prescribed stimulant medication was markedly lower for both pediatricians (51.1%; 95% CI: 9.6-91.4) and GPs (18.7%; 95% CI: 4.1-45.5).

Conclusion: Adherence to CPGs for ADHD by pediatricians was generally high. Adherence by GPs was lower across most domains; timely recognition of medication side effects is a particular area for improvement.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245916PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869992PMC
February 2021

Senior clinical and business managers' perspectives on the influence of different funding mechanisms, and barriers and enablers to implementing models of employing General Practitioners in or alongside emergency departments: Qualitative study.

Health Policy 2021 Apr 22;125(4):482-488. Epub 2021 Jan 22.

PRIME Centre Wales, Division of Population Medicine, 8(th) Floor Neuadd Meirionnydd, Heath Park, Cardiff, UK. Electronic address:

Purpose: Health policy in England has advocated the use of primary care clinicians at emergency departments to address pressures from rising attendances. This study explored senior managers' perspective son funding mechanisms used to implement the policy and experiences of success or challenges in introducing GPs in or alongside emergency departments.

Methods: The perspectives of senior clinical, business and finance managers with responsibility for emergency department services and on-site primary care service implementation were investigated in semi-structured interviews with 31 managers at 12 type-1 emergency departments in England and Wales (February 2018 - September 2019). Emergency departments operated one of three GP models or had prior experience of implementing a GP model. Interviews were thematically analysed.

Results: Perceived successful GPs models in emergency departments were reliant on well-organised and unified funding mechanisms, appropriate staffing and governance, and consideration of population demands and needs. Funding mechanisms and the flow of funds were reported as complex, especially in Inside-parallel GP models. The most efficient mechanisms were described at departments where funding was unified, in collaboration with health and community care services. Staffing with local, experienced GPs was important. There were cautions from experiences with private locum providers.

Conclusion: Our findings contribute to debates about implementing policy on how primary care clinicians are effectively and safely deployed in emergency departments and how local context should be considered.
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http://dx.doi.org/10.1016/j.healthpol.2020.11.016DOI Listing
April 2021

Implementing large-system, value-based healthcare initiatives: a realist study protocol for seven natural experiments.

BMJ Open 2020 12 22;10(12):e044049. Epub 2020 Dec 22.

Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia.

Introduction: Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond 'what works' towards more nuanced understanding of 'what tends to work for whom under which circumstances'. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts.

Methods And Analysis: This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context-mechanism-outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed.

Ethics And Dissemination: Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.
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http://dx.doi.org/10.1136/bmjopen-2020-044049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757496PMC
December 2020

Reducing preventable harm to residents in aged care: A systems approach.

Australas J Ageing 2021 Mar 2;40(1):72-76. Epub 2020 Oct 2.

Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.

Residents in Australian aged care facilities can suffer serious preventable harm from incidents ('adverse events' (AEs)). An inadequate response to AEs by aged care facilities can compound distress to residents and their families/carers. Facilities have an obligation to respond to and investigate AEs involving residents, learn from them, and take action to reduce the chance of them reoccurring . Residential aged care facilities have a duty to create a culture where staff, residents and families/carers feel comfortable reporting AEs or complaints; there is adequate time and resources to manage AEs and complaints; and feedback is provided to staff, residents and their families/carers on the results of investigations into AEs/complaints. The Aged Care Quality and Safety Commission's role should encompass additional governance functions such as sharing results and lessons learnt from AEs, complaints and investigations across Australia, assuring the quality of investigations conducted by facilities, and undertaking national system-wide investigations.
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http://dx.doi.org/10.1111/ajag.12861DOI Listing
March 2021

Emergency department clinical leads' experiences of implementing primary care services where GPs work in or alongside emergency departments in the UK: a qualitative study.

BMC Emerg Med 2020 08 14;20(1):62. Epub 2020 Aug 14.

Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK.

Background: To manage increasing demand for emergency and unscheduled care NHS England policy has promoted services in which patients presenting to Emergency Departments (EDs) with non-urgent problems are directed to general practitioners (GPs) and other primary care clinicians working within or alongside emergency departments. However, the ways that hospitals have implemented primary care services in EDs are varied. The aim of this study was to describe ED clinical leads' experiences of implementing and delivering 'primary care services' and 'emergency medicine services' where GPs were integrated into the ED team.

Methods: We conducted interviews with ED clinical leads in England (n = 19) and Wales (n = 2). We used framework analysis to analyse interview transcripts and explore differences across 'primary care services', 'emergency medicine services' and emergency departments without primary care services.

Results: In EDs with separate primary care services, success was reported when having a distinct workforce of primary care clinicians, who improved waiting times and flow by seeing primary care-type patients in a timely way, using fewer investigations, and enabling ED doctors to focus on more acutely unwell patients. Some challenges were: trying to align their service with the policy guidance, inconsistent demand for primary care, accessible community primary care services, difficulties in recruiting GPs, lack of funding, difficulties in agreeing governance protocols and establishing effective streaming pathways. Where GPs were integrated into an ED workforce success was reported as managing the demand for both emergency and primary care and reducing admissions.

Conclusions: Introducing a policy advocating a preferred model of service to address primary care demand was not useful for all emergency departments. To support successful and sustainable primary care services in or alongside EDs, policy makers and commissioners should consider varied ways that GPs can be employed to manage variation in local demand and also local contextual factors such as the ability to recruit and retain GPs, sustainable funding, clear governance frameworks, training, support and guidance for all staff. Whether or not streaming to a separate primary care service is useful also depended on the level of primary care demand.
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http://dx.doi.org/10.1186/s12873-020-00358-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429882PMC
August 2020

Assessing guideline adherence in the management of type 1 diabetes mellitus in Australian children: a population-based sample survey.

BMJ Open Diabetes Res Care 2020 07;8(1)

Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia.

Introduction: To estimate adherence to clinical practice guidelines in selected settings at a population level for Australian children with type 1 diabetes mellitus.

Research Design And Methods: Medical records of children with type 1 diabetes mellitus aged 0-15 years in 2012-2013 were targeted for sampling across inpatient, emergency department and community visits with specialist pediatricians in regional and metropolitan areas and tertiary pediatric hospitals in three states where approximately 60% of Australian children reside. Clinical recommendations extracted from two clinical practice guidelines were used to audit adherence. Results were aggregated across types of care (diagnosis, routine care, emergency care).

Results: Surveyors conducted 6346 indicator assessments from an audit of 539 healthcare visits by 251 children. Average adherence across all indicators was estimated at 79.9% (95% CI 69.5 to 88.0). Children with type 1 diabetes mellitus have higher rates of behavioral and psychological disorders, but only a third of children (37.9%; 95% CI 11.7 to 70.7) with suboptimal glycemic control (eg, hemoglobin A1c >10% or 86 mmol/mol) were screened for psychological disorders using a validated tool; this was the only indicator with <50% estimated adherence. Adherence by care type was: 86.1% for diagnosis (95% CI 76.7 to 92.7); 78.8% for routine care (95% CI 65.4 to 88.9) and 83.9% for emergency care (95% CI 78.4 to 88.5).

Conclusions: Most indicators for care of children with type 1 diabetes mellitus were adhered to. However, there remains room to improve adherence to guidelines for optimization of practice consistency and minimization of future disease burden.
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http://dx.doi.org/10.1136/bmjdrc-2019-001141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380831PMC
July 2020

Challenges of recruiting emergency department patients to a qualitative study: a thematic analysis of researchers' experiences.

BMC Med Res Methodol 2020 06 11;20(1):151. Epub 2020 Jun 11.

Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales.

Background: At times of increasing pressure on emergency departments, and the need for research into different models of service delivery, little is known about how to recruit patients for qualitative research in emergency departments. We report from one study which aimed to collect evidence on patients' experiences of attending emergency departments with different models of using general practitioners, but faced challenges in recruiting patients. This paper aims to identify and reflect on the challenges faced at all stages of patient recruitment, from identifying and inviting eligible patients, consenting them for participation and finally to engaging them in interviews, and make recommendations based on our learning.

Methods: A thematic analysis was carried out on field-notes taken during research visits and meeting minutes of discussions to review and improve patient recruitment throughout the study.

Results: The following factors influenced the success of patient recruitment in the emergency department setting: complicated or time-consuming electronic health record systems for identifying patients; narrow participant eligibility criteria; limited research nurse support; and lack of face-to-face communication between researchers and eligible patients.

Conclusions: This paper adds to the methodological evidence for improving patient recruitment in different settings, with a focus on qualitative research in emergency departments. Our findings have implications for future studies attempting to recruit patients in similar settings.
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http://dx.doi.org/10.1186/s12874-020-01039-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288546PMC
June 2020

iCareTrack: measuring the appropriateness of eyecare delivery in Australia.

Ophthalmic Physiol Opt 2020 07 3;40(4):433-441. Epub 2020 Jun 3.

School of Optometry and Vision Science, University of New South Wales, Sydney, Australia.

Purpose: To meet the needs of an ageing population and optimise health expenditure, delivery of care should be based on evidence. However, the level of evidence-based care delivered to patients with eye conditions is rarely assessed. This study thus aimed to determine the percentage of eyecare encounters at which a sample of adult Australians received appropriate care (i.e., eyecare in line with evidence-based or consensus-based guidelines).

Methods: A cross-sectional retrospective review of optometry practice records was conducted using random stratified (by state) sampling in mainland Australia. Eighty-five clinical indicators were developed from evidence-based clinical practice guideline recommendations and refined by panels of experts using a modified Delphi process. Healthcare records of patients 18 years and over were examined against these indicators, representing appropriate care for three common eye conditions (preventative eyecare, glaucoma, and diabetic eyecare). Encounters occurred in optometry practices that were selected to be representative of the socioeconomic profile of Australian practices. The primary outcome measure was percentage compliance of eyecare delivery against the clinical indicators.

Results: From 426 optometry practices contacted by mail or telephone, 90 (21%) replied, 46 proved eligible and 42 were included in the study and visited for data collection. From these 1260 patient records were reviewed. Appropriate eyecare was received by Australian patients at an average of 71% (95%CI 70%, 73%) of eligible encounters. The percentage of appropriateness of eyecare at the condition level for preventative, glaucoma and diabetic eyecare was 81% (95%CI 79%, 83%), 63% (95%CI 61%, 64%), and 69% (95%CI 66%, 73%), respectively. Appropriateness of eyecare delivery was lowest for the domains of history taking and physical examination for all eye conditions.

Conclusions: There were pockets of excellence but consistent delivery of appropriate eyecare needs improvement, and gaps in eyecare delivery should be addressed.
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http://dx.doi.org/10.1111/opo.12699DOI Listing
July 2020

A Mixed-Methods Systematic Review of the Effectiveness and Experiences of Quality Improvement Interventions in Radiology.

J Patient Saf 2020 May 18. Epub 2020 May 18.

Australian Patient Safety Foundation, University of South Australia, Adelaide, South Australia, Australia.

Objective: This study aimed to compile and synthesize evidence regarding the effectiveness of quality improvement interventions in radiology and the experiences and perspectives of staff and patients.

Methods: Databases searched for both published and unpublished studies were as follows: EMBASE, MEDLINE, CINAHL, Joanna Briggs Institute, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, Web of Science, Mednar, Trove, Google Gray, OCLC WorldCat, and Dissertations and Theses. This review included both qualitative and quantitative studies of patients undergoing radiological examinations and/or medical imaging health care professionals; a broad range of quality improvement interventions including introduction of health information technology, effects of training and education, improved reporting, safety programs, and medical devices; the experiences and perspectives of staff and patients; context of radiological setting; a broad range of outcomes including patient safety; and a result-based convergent synthesis design.

Results: Eighteen studies were selected from 4846 identified by a systematic literature search. Five groups of interventions were identified: health information technology (n = 6), training and education (n = 6), immediate and critical reporting (n = 3), safety programs (n = 2), and the introduction of mobile radiography (n = 1), with demonstrated improvements in outcomes, such as improved operational and workflow efficiency, report turnaround time, and teamwork and communication.

Conclusions: The findings were constrained by the limited range of interventions and outcome measures. Further research should be conducted with study designs that might produce findings that are more generalizable, examine the other dimensions of quality, and address the issues of cost and risk versus benefit.
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http://dx.doi.org/10.1097/PTS.0000000000000709DOI Listing
May 2020

The patient died: What about involvement in the investigation process?

Int J Qual Health Care 2020 Jun;32(5):342-346

Australian Institute of Health Innovation, Macquarie University, New South Wales.

Patient and family involvement is high on the international quality and safety agenda. In this paper, we consider possible ways of involving families in investigations of fatal adverse events and how their greater participation might improve the quality of investigations. The aim is to increase awareness among healthcare professionals, accident investigators, policymakers and researchers and examine how research and practice can develop in this emerging field. In contrast to relying mainly on documentation and staff recollections, family involvement can result in the investigation having access to richer information, a more holistic picture of the event and new perspectives on who was involved and can positively contribute to the family's emotional satisfaction and perception of justice being done. There is limited guidance and research on how to constitute effective involvement. There is a need for co-designing the investigation process, explicitly agreeing the family's level of involvement, supporting and preparing the family, providing easily accessible user-friendly language and using different methods of involvement (e.g. individual interviews, focus group interviews and questionnaires), depending on the family's needs.
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http://dx.doi.org/10.1093/intqhc/mzaa034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7299194PMC
June 2020

Assessing the appropriateness of paediatric antibiotic overuse in Australian children: a population-based sample survey.

BMC Pediatr 2020 04 24;20(1):185. Epub 2020 Apr 24.

Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, New South Wales, 2109, Australia.

Background: Infections caused by antibiotic resistant pathogens are increasing, with antibiotic overuse a key contributing factor.

Objective: The CareTrack Kids (CTK) team assessed the care of children in Australia aged 0-15 years in 2012 and 2013 to determine the proportion of care in line with clinical practice guidelines (CPGs) for 17 common conditions. This study analyses indicators relating to paediatric antibiotic overuse to identify those which should be prioritised by antimicrobial stewardship and clinical improvement programs.

Method: A systematic search was undertaken for national and international CPGs relevant to 17 target conditions for Australian paediatric care in 2012-2013. Recommendations were screened and ratified by reviewers. The sampling frame comprised three states containing 60% of the Australian paediatric population (South Australia, New South Wales and Queensland). Multi-stage cluster sampling was used to select general practices, specialist paediatric practices, emergency departments and hospital inpatient services, and medical records within these. Medical records were reviewed by experienced paediatric nurses, trained to assess eligibility for indicator assessment and compliance with indicators. Adherence rates were estimated.

Results: Ten antibiotic overuse indicators were identified; three for tonsillitis and one each for seven other conditions. A total of 2621 children were assessed. Estimated adherence for indicators ranged from 13.8 to 99.5% while the overall estimate of compliance was 61.9% (95% CI: 47.8-74.7). Conditions with high levels of appropriate avoidance of antibiotics were gastroenteritis and atopic eczema without signs of infection, bronchiolitis and croup. Indicators with less than 50% adherence were asthma exacerbation in children aged > 2 years (47.1%; 95% CI: 33.4-61.1), sore throat with no other signs of tonsillitis (40.9%; 95% CI: 16.9, 68.6), acute otitis media in children aged > 12 months who were mildly unwell (13.8%; 95% CI: 5.1, 28.0), and sore throat and associated cough in children aged < 4 years (14.3%; 95% CI: 9.9, 19.7).

Conclusion: The results of this study identify four candidate indicators (two for tonsillitis, one for otitis media and one for asthma) for monitoring by antibiotic stewardship and clinical improvement programs in ambulatory and hospital paediatric care, and intervention if needed.
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http://dx.doi.org/10.1186/s12887-020-02052-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7181474PMC
April 2020

A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.

Int J Qual Health Care 2020 May;32(3):184-189

Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia.

Objective: To describe incidents of retained surgical items, including their characteristics and the circumstances in which they occur.

Design: A qualitative content analysis of root cause analysis investigation reports.

Setting: Public health services in Victoria, Australia, 2010-2015.

Participants: Incidents of retained surgical items as described by 31 root cause analysis investigation reports.

Main Outcome Measure(s): The type of retained surgical item, the length of time between the item being retained and detected and qualitative descriptors of the contributing factors and the circumstances in which the retained surgical items occurred.

Results: Surgical packs, drain tubes and vascular devices comprised 68% (21/31) of the retained surgical items. Nearly one-quarter of the retained surgical items were detected either immediately in the post-operative period or on the day of the procedure (7/31). However, about one-sixth (5/31) were only detected after 6 months, with the longest period being 18 months. Contributing factors included complex or multistage surgery; the use of packs not specific to the purpose of the surgery; and design features of the surgical items.

Conclusion: Retained drains occurred in the post-operative phase where surgical counts are not applicable and clinician situational awareness may not be as great. Root cause analysis investigation reports can be a valuable means of characterizing infrequently occurring adverse events such as retained surgical items. They may detect incidents that are not detected by other data collections and can inform the design enhancements and development of technologies to reduce the impact of retained surgical items.
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http://dx.doi.org/10.1093/intqhc/mzaa005DOI Listing
May 2020

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales.

Addiction 2020 11 27;115(11):2066-2076. Epub 2020 Apr 27.

Cardiff University, Cardiff, UK.

Background And Aims: Opioid substitution treatment is used in many countries as an effective harm minimization strategy. There is a need for more information about patient safety incidents and the resulting harm relating to this treatment. We aimed to characterize patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care by: (i) identifying the sources and nature of harm and (ii) describing and interpreting themes to identify priorities to focus future improvement work.

Design: Mixed-methods study examining patient safety incident reports involving opioid substitution treatment with either methadone or buprenorphine in community-based care.

Setting: Data submitted between 2005 and 2015 from the National Reporting and Learning System (NRLS), a national repository of patient safety incident reports from across England and Wales.

Participants: A total of 2284 reports were identified involving patients receiving community-based opioid substitution treatment.

Measurements: Incident type, contributory factors, incident outcome and severity of harm. Analysis involved data coding, processing and iterative generation of data summaries using descriptive statistical and thematic analysis.

Findings: Most risks of harm from opioid substitution treatment came from failure in one of four processes of care delivery: prescribing opioid substitution (n = 151); supervised dispensing (n = 248); non-supervised dispensing (n = 318); and monitoring and communication (n = 1544). Most incidents resulting in harm involved supervised or non-supervised dispensing (n = 91 of 127, 72%). Staff- (e.g. slips during task execution, not following protocols) and organization-related (e.g. poor working conditions or poor continuity of care between services) contributory factors were identified for more than half of incidents.

Conclusions: Risks of harm in delivering opioid substitute treatment in England and Wales appear to arise out of failures in four processes: prescribing opioid substitution, supervised dispensing, non-supervised dispensing and monitoring and communication.
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http://dx.doi.org/10.1111/add.15039DOI Listing
November 2020

Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports.

Arch Dis Child 2020 08 6;105(8):731-737. Epub 2020 Mar 6.

Division of Population Medicine, Cardiff University, Cardiff, UK

Purpose: Patient safety failures are recognised as a global threat to public health, yet remain a leading cause of death internationally. Vulnerable children are inversely more in need of high-quality primary health and social-care but little is known about the quality of care received. Using national patient safety data, this study aimed to characterise primary care-related safety incidents among vulnerable children.

Methods: This was a cross-sectional mixed methods study of a national database of patient safety incident reports occurring in primary care settings. Free-text incident reports were coded to describe incident types, contributory factors, harm severity and incident outcomes. Subsequent thematic analyses of a purposive sample of reports was undertaken to understand factors underpinning problem areas.

Results: Of 1183 reports identified, 572 (48%) described harm to vulnerable children. Sociodemographic analysis showed that included children had child protection-related (517, 44%); social (353, 30%); psychological (189, 16%) or physical (124, 11%) vulnerabilities. Priority safety issues included: poor recognition of needs and subsequent provision of adequate care; insufficient provider access to accurate information about vulnerable children, and delayed referrals between providers.

Conclusion: This is the first national study using incident report data to explore unsafe care amongst vulnerable children. Several system failures affecting vulnerable children are highlighted, many of which pose internationally recognised challenges to providers aiming to deliver safe care to this at-risk cohort. We encourage healthcare organisations globally to build on our findings and explore the safety and reliability of their healthcare systems, in order to sustainably mitigate harm to vulnerable children.
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http://dx.doi.org/10.1136/archdischild-2019-318406DOI Listing
August 2020

Guideline adherence in the management of head injury in Australian children: A population-based sample survey.

PLoS One 2020 11;15(2):e0228715. Epub 2020 Feb 11.

Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.

Background: Head injuries in children are a common and potentially devastating presentation. The CareTrack Kids (CTK) study assessed care of Australian children aged 0-15 years, in 2012 and 2013, to evaluate the proportion in line with guideline-based indicators for 17 common conditions. Overall adherence to guideline-based recommended practice occurred 59.8% of care encounters (95% CI: 57.5-62.0), and 78.3% (95% CI: 75.1-81.2) for head injury. This paper presents results for head injury, at indicator level.

Methods: A modified version of the RAND-UCLA method of indicator development was used. Indicators, measurable components of a standard or guideline, were developed from international and national guidelines relating to head injury in children and were ratified by clinical experts using a Delphi process. Paediatric nurses extracted data from medical records from general practitioners (GPs), emergency departments (EDs) and inpatient wards in Queensland, New South Wales and South Australia, for children under 15 years receiving care in 2012-13. Our purpose was to estimate the percentage adherent for each indicator.

Results: The medical records of 629 children with head injury were examined. Fifty-one percent of children were under 5 years old, with more males (61%) than females. Thirty-eight indicators were assessed. Avoidance of nasotracheal airways (100%; 95% CI: 99.4-100) or nasogastric tubes (99.7%; 95% CI: 98.5-100) for children with a head injury had the highest adherence. Indicators relating to primary and secondary assessment of head injuries were mostly adhered to. However, adherence to other indicators was poor (e.g., documentation of the past history of children (e.g., presence or absence of seizures) before the injury; 29.9% (95% CI: 24.5-35.7)), and for others was difficult to estimate with confidence due to small sample sizes (e.g., Children with a head injury who were intubated had PaO2 above 80mm Hg; 56.0% (95% CI: 28.6-80.9)). Indicators guiding clinical decision making regarding the need for CT scan had insufficient data to justify reporting.

Conclusion: This study highlights that management of head injury in children mostly follows guidelines, but also flags some specific areas of inconsistency. Individual sites are encouraged to use these results to guide investigation of local practices and inform quality improvement endeavours.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228715PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012413PMC
May 2020

Can benchmarking Australian hospitals for quality identify and improve high and low performers? Disseminating research findings for hospitals.

Int J Qual Health Care 2020 Feb;32(Supplement_1):84-88

Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW 2109, Australia.

This paper examines the principles of benchmarking in healthcare and how benchmarking can contribute to practice improvement and improved health outcomes for patients. It uses the Deepening our Understanding of Quality in Australia (DUQuA) study published in this Supplement and DUQuA's predecessor in Europe, the Deepening our Understanding of Quality improvement in Europe (DUQuE) study, as models. Benchmarking is where the performances of institutions or individuals are compared using agreed indicators or standards. The rationale for benchmarking is that institutions will respond positively to being identified as a low outlier or desire to be or stay as a high performer, or both, and patients will be empowered to make choices to seek care at institutions that are high performers. Benchmarking often begins with a conceptual framework that is based on a logic model. Such a framework can drive the selection of indicators to measure performance, rather than their selection being based on what is easy to measure. A Donabedian range of indicators can be chosen, including structure, process and outcomes, created around multiple domains or specialties. Indicators based on continuous variables allow organizations to understand where their performance is within a population, and their interdependencies and associations can be understood. Benchmarking should optimally target providers, in order to drive them towards improvement. The DUQuA and DUQuE studies both incorporated some of these principles into their design, thereby creating a model of how to incorporate robust benchmarking into large-scale health services research.
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http://dx.doi.org/10.1093/intqhc/mzz109DOI Listing
February 2020

Using accreditation surveyors to conduct health services research: a qualitative, comparative study in Australia.

Int J Qual Health Care 2020 Feb;32(Supplement_1):89-98

Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, NSW 2109, Australia.

Objective: Healthcare accreditation surveyors are well positioned to gain access to hospitals and apply their existing data collection skills to research. Consequently, we contracted and trained a surveyor cohort to collect research data for the Deepening our Understanding of Quality in Australia (DUQuA) project. The aim of this study is to explore and compare surveyors' perceptions and experiences in collecting quality and safety data for accreditation and for health services research.

Design: A qualitative, comparative study.

Setting And Participants: Ten surveyors participated in semi-structured interviews, which were audio recorded, transcribed and coded using Nvivo11. Interview transcripts of participants were analysed thematically and separately, providing an opportunity for comparison and for identifying common themes and subthemes.

Intervention(s): None.

Main Outcome Measure(s): Topics addressed data collection for healthcare accreditation and research, including preparation and training, structure, organization, attitudes and behaviours of staff and perceptions of their role.

Results: Five themes and ten subthemes emerged from the interviews: (1) overlapping facilitators for accreditation and research data collection, (2) accreditation-specific facilitators, (3) overlapping barriers for accreditation and research data collection, (4) research data collection-specific barriers and (5) needs and recommendations. Subthemes were (1.1) preparation and training availability, (1.2) prior knowledge and experiences; (2.1) ease of access, (2.2) high staff engagement, (3.1) time, (4.1) poor access and structure, (4.2) lack of staff engagement, (4.3) organizational changes; (5.1) short-notice accreditation and (5.2) preparation for future research.

Conclusions: Although hospital accreditation and research activities require different approaches to data collection, we found that suitably trained accreditation surveyors were able to perform both activities effectively. The barriers surveyors encountered when collecting data for research provide insight into the challenges that may be faced when visiting hospitals for short-notice accreditation.
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http://dx.doi.org/10.1093/intqhc/mzz110DOI Listing
February 2020

Management of fever in Australian children: a population-based sample survey.

BMC Pediatr 2020 01 13;20(1):16. Epub 2020 Jan 13.

Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, North Ryde, NSW, 2109, Australia.

Background: Fever in childhood is a common acute presentation requiring clinical triage to identify the few children who have serious underlying infection. Clinical practice guidelines (CPGs) have been developed to assist clinicians with this task. This study aimed to assess the proportion of care provided in accordance with CPG recommendations for the management of fever in Australian children.

Methods: Clinical recommendations were extracted from five CPGs and formulated into 47 clinical indicators for use in auditing adherence. Indicators were categorised by phase of care: assessment, diagnosis and treatment. Patient records from children aged 0 to 15 years were sampled from general practices (GP), emergency departments (ED) and hospital admissions in randomly-selected health districts in Queensland, New South Wales and South Australia during 2012 and 2013. Paediatric nurses, trained to assess eligibility for indicator assessment and adherence, reviewed eligible medical records. Adherence was estimated by individual indicator, phase of care, age-group and setting.

Results: The field team conducted 14,879 eligible indicator assessments for 708 visits by 550 children with fever in 58 GP, 34 ED and 28 hospital inpatient settings. For the 33 indicators with sufficient data, adherence ranged from 14.7 to 98.1%. Estimated adherence with assessment-related indicators was 51.3% (95% CI: 48.1-54.6), 77.5% (95% CI: 65.3-87.1) for diagnostic-related indicators and 72.7% (95% CI: 65.3-79.3) for treatment-related indicators. Adherence for children < 3 months of age was 73.4% (95% CI: 58.0-85.8) and 64.7% (95% CI: 57.0-71.9) for children 3-11 months of age, both significantly higher than for children aged 4-15 years (53.5%; 95% CI: 50.0-56.9). The proportion of adherent care for children attending an ED was 77.5% (95% CI: 74.2-80.6) and 76.7% (95% CI: 71.7-81.3) for children admitted to hospital, both significantly higher than for children attending a GP (40.3%; 95% CI: 34.6-46.1).

Conclusions: This study reports a wide range of adherence by clinicians to 47 indicators of best practice for the management of febrile children, sampled from urban and rural regions containing 60% of the Australian paediatric population. Documented adherence was lowest for indicators related to patient assessment, for care provided in GP settings, and for children aged 4-15 years.
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http://dx.doi.org/10.1186/s12887-020-1911-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6956501PMC
January 2020

The quality of preventive care for pre-school aged children in Australian general practice.

BMC Med 2019 12 6;17(1):218. Epub 2019 Dec 6.

Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia.

Background: Variable and poor care quality are important causes of preventable patient harm. Many patients receive less than recommended care, but the extent of the problem remains largely unknown. The CareTrack Kids (CTK) research programme sought to address this evidence gap by developing a set of indicators to measure the quality of care for common paediatric conditions. In this study, we focus on one clinical area, 'preventive care' for pre-school aged children. Our objectives were two-fold: (i) develop and validate preventive care quality indicators and (ii) apply them in general medical practice to measure adherence.

Methods: Clinical experts (n = 6) developed indicator questions (IQs) from clinical practice guideline (CPG) recommendations using a multi-stage modified Delphi process, which were pilot tested in general practice. The medical records of Australian children (n = 976) from general practices (n = 80) in Queensland, New South Wales and South Australia identified as having a consultation for one of 17 CTK conditions of interest were retrospectively reviewed by trained paediatric nurses. Statistical analyses were performed to estimate percentage compliance and its 95% confidence intervals.

Results: IQs (n = 43) and eight care 'bundles' were developed and validated. Care was delivered in line with the IQs in 43.3% of eligible healthcare encounters (95% CI 30.5-56.7). The bundles of care with the highest compliance were 'immunisation' (80.1%, 95% CI 65.7-90.4), 'anthropometric measurements' (52.7%, 95% CI 35.6-69.4) and 'nutrition assessments' (38.5%, 95% CI 24.3-54.3), and lowest for 'visual assessment' (17.9%, 95% CI 8.2-31.9), 'musculoskeletal examinations' (24.4%, 95% CI 13.1-39.1) and 'cardiovascular examinations' (30.9%, 95% CI 12.3-55.5).

Conclusions: This study is the first known attempt to develop specific preventive care quality indicators and measure their delivery to Australian children in general practice. Our findings that preventive care is not reliably delivered to all Australian children and that there is substantial variation in adherence with the IQs provide a starting point for clinicians, researchers and policy makers when considering how the gap between recommended and actual care may be narrowed. The findings may also help inform the development of specific improvement interventions, incentives and national standards.
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http://dx.doi.org/10.1186/s12916-019-1455-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6896286PMC
December 2019

Diagnostic error in the emergency department: learning from national patient safety incident report analysis.

BMC Emerg Med 2019 12 4;19(1):77. Epub 2019 Dec 4.

Cardiff University, Cardiff, UK.

Background: Diagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. We sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015 and to identify the priority areas for intervention to reduce their occurrence.

Methods: A cross-sectional mixed-methods design using an exploratory descriptive analysis and thematic analysis of patient safety incident reports. Primary data were extracted from a national database of patient safety incidents. Reports were filtered for emergency department settings, diagnostic error (as classified by the reporter), from 2013 to 2015. These were analysed for the chain of events, contributory factors and harm outcomes.

Results: There were 2288 cases of confirmed diagnostic error: 1973 (86%) delayed and 315 (14%) wrong diagnoses. One in seven incidents were reported to have severe harm or death. Fractures were the most common condition (44%), with cervical-spine and neck of femur the most frequent types. Other common conditions included myocardial infarctions (7%) and intracranial bleeds (6%). Incidents involving both delayed and wrong diagnoses were associated with insufficient assessment, misinterpretation of diagnostic investigations and failure to order investigations. Contributory factors were predominantly human factors, including staff mistakes, healthcare professionals' inadequate skillset or knowledge and not following protocols.

Conclusions: Systems modifications are needed that provide clinicians with better support in performing patient assessment and investigation interpretation. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.
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http://dx.doi.org/10.1186/s12873-019-0289-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6894198PMC
December 2019

Quality of care for acute abdominal pain in children.

BMJ Qual Saf 2020 06 27;29(6):509-516. Epub 2019 Nov 27.

Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia

Objective: To assess quality of care for children presenting with acute abdominal pain using validated indicators.

Design: Audit of care quality for acute abdominal pain according to 21 care quality indicators developed and validated in four stages.

Setting And Participants: Medical records of children aged 1-15 years receiving care in 2012-2013 were sampled from 57 general practitioners, 34 emergency departments (ED) and 28 hospitals across three Australian states; 6689 medical records were screened for visits for acute abdominal pain and audited by trained paediatric nurses.

Outcome Measures: Adherence to 21 care quality indicators and three bundles of indicators: bundle A-History; bundle B-Examination; bundle C-Imaging.

Results: Five hundred and fourteen children had 696 visits for acute abdominal pain and adherence was assessed for 9785 individual indicators. The overall adherence was 69.9% (95% CI 64.8% to 74.6%). Adherence to individual indicators ranged from 21.6% for assessment of dehydration to 91.4% for appropriate ordering of imaging. Adherence was low for bundle A-History (29.4%) and bundle B-Examination (10.2%), and high for bundle C-Imaging (91.4%). Adherence to the 21 indicators overall was significantly lower in general practice (62.7%, 95% CI 57.0% to 68.1%) compared with ED (86.0%, 95% CI 83.4% to 88.4%; p<0.0001) and hospital inpatient settings (87.9%, 95% CI 83.1% to 91.8%; p<0.0001).

Conclusions: There was considerable variation in care quality for indicator bundles and care settings. Future work should explore how validated care quality indicator assessments can be embedded into clinical workflows to support continuous care quality improvement.
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http://dx.doi.org/10.1136/bmjqs-2019-010088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286043PMC
June 2020

Deepening our Understanding of Quality in Australia (DUQuA): An overview of a nation-wide, multi-level analysis of relationships between quality management systems and patient factors in 32 hospitals.

Int J Qual Health Care 2020 Feb;32(Supplement_1):8-21

Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW 2109, Australia.

Objective: The Deepening our Understanding of Quality in Australia (DUQuA) project is a multisite, multi-level, cross-sectional study of 32 of the largest hospitals in Australia. This overview examines relationships between (i) organization-level quality management systems and department-level quality management strategies and (ii) patient-level measures (clinical treatment processes, patient-reported perceptions of care and clinical outcomes) within Australian hospitals.

Design: We examined hospital quality improvement structures, processes and outcomes, collecting data at organization, department and patient levels for acute myocardial infarction (AMI), hip fracture and stroke. Data sources included surveys of quality managers, clinicians and patients, hospital visits, medical record reviews and national databases. Outcomes data and patient admissions data were analysed. Relationships between measures were evaluated using multi-level models. We based the methods on the Deepening our Understanding of Quality Improvement in Europe (DUQuE) framework, extending that work in parts and customizing the design to Australian circumstances.

Setting, Participants And Outcome Measures: The 32 hospitals, containing 119 participating departments, provided wide representation across metropolitan, inner and outer regional Australia. We obtained 31 quality management, 1334 clinician and 857 patient questionnaires, and conducted 2401 medical record reviews and 151 external assessments. External data via a secondary source comprised 14 460 index patient admissions across 14 031 individual patients. Associations between hospital, Emergency Department (ED) and department-level systems and strategies and five patient-level outcomes were assessed: 19 of 165 associations (11.5%) were statistically significant, 12 of 79 positive associations (15.2%) and 7 of 85 negative associations (8.2%).

Results: We did not find clear relationships between hospital-level quality management systems, ED or department quality strategies and patient-level outcomes. ED-level clinical reviews were related to adherence to clinical practice guidelines for AMI, hip fracture and stroke, but in different directions. The results, when considered alongside the DUQuE results, are suggestive that front line interventions may be more influential than department-level interventions when shaping quality of care and that multi-pronged strategies are needed. Benchmark reports were sent to each participating hospital, stimulating targeted quality improvement activities.

Conclusions: We found no compelling relationships between the way care is organized and the quality of care across three targeted patient-level outcome conditions. The study was cross-sectional, and thus we recommend that the relationships studied should be assessed for changes across time. Tracking care longitudinally so that quality improvement activities are monitored and fed back to participants is an important initiative that should be given priority as health systems strive to develop their capacity for quality improvement over time.
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http://dx.doi.org/10.1093/intqhc/mzz103DOI Listing
February 2020

Appropriate management of acute gastroenteritis in Australian children: A population-based study.

PLoS One 2019 7;14(11):e0224681. Epub 2019 Nov 7.

Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia.

Objectives: To determine the proportion of care provided to children with acute gastroenteritis (AGE) in Australia consistent with clinical practice guidelines.

Methods: Indicators were developed from national and international clinical practice guideline (CPG) recommendations and validated by an expert panel. Medical records from children ≤15 years presenting with AGE in three healthcare settings-Emergency Department (ED), hospital admissions and General Practitioner (GP) consultations-from randomly selected health districts across three Australian States were reviewed. Records were audited against 35 indicators by trained paediatric nurses, to determine adherence to CPGs during diagnosis, treatment, and ongoing management.

Results: A total of 14,434 indicator assessments were performed from 854 healthcare visits for AGE by 669 children, across 75 GPs, 34 EDs and 26 hospital inpatient services. Documented adherence to guidelines across all healthcare settings was 45.5% for indicators relating to diagnosis (95% CI: 40.7-50.4), 96.1% for treatment (95% CI: 94.8-97.1) and 57.6% for ongoing management (95% CI: 51.3-63.7). Adherence varied by healthcare setting, with adherence in GPs (54.6%; 95% CI: 51.1-58.1) lower than for either ED settings (84.7%; 95% CI: 82.4-86.9) or for inpatients (84.3%; 95% CI: 80.0-87.9); p<0.0001 for both differences. The difference between settings was driven by differences in the diagnosis and ongoing management phases of care.

Conclusions: Adherence to clinical guidelines for children presenting to healthcare providers with AGE varies according to phase of care and healthcare setting. Although appropriate diagnostic assessment and ongoing management phase procedures are not well documented in medical records (particularly in the GP setting), in the treatment phase children are treated in accordance with guidelines over 90% of the time.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0224681PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837505PMC
March 2020

Assessing the adherence to guidelines in the management of croup in Australian children: a population-based sample survey.

Int J Qual Health Care 2019 Dec;31(10):759-767

Department of Respiratory Medicine, Sydney Children's Hospital, High St., Randwick, NSW, 2031, Australia.

Objective: To determine the extent to which care received by Australian children presenting with croup is in agreement with Clinical Practice Guidelines (CPGs).

Design: Retrospective population-based sample survey. Croup clinical indicators were derived from CPGs.

Data Sources/study Setting: Medical records from three healthcare settings were sampled for selected visits in 2012 and 2013 in three Australian states.

Data Collection: Data were collected by nine experienced paediatric nurses, trained to assess eligibility for indicator assessment and adherence to CPGs. Surveyors undertook criterion-based medical record reviews using an electronic data collection tool.

Results: Documented guideline adherence was lower for general practitioners (65.9%; 95% CI: 60.8-70.6) than emergency departments (91.1%; 95% CI: 89.5-92.5) and inpatient admissions (91.3%; 95% CI: 88.1-93.9). Overall adherence was very low for a bundle of 10 indicators related to assessment (4.5%; 95% CI: 2.4-7.6) but higher for a bundle of four indicators relating to the avoidance of inappropriate therapy (83.1%; 95% CI: 59.5-96.0).

Conclusions: Most visits for croup were characterized by appropriate treatment in all healthcare settings. However, most children had limited documented clinical assessments, and some had unnecessary tests or inappropriate therapy, which has potential quality and cost implications. Universal CPG and clinical assessment tools may increase clinical consistency.
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http://dx.doi.org/10.1093/intqhc/mzz088DOI Listing
December 2019

Systematic review of the appropriateness of eye care delivery in eye care practice.

BMC Health Serv Res 2019 Sep 6;19(1):646. Epub 2019 Sep 6.

School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, 2052, Australia.

Background: Health care systems are continually being reformed, however care improvement and intervention effectiveness are often assumed, not measured. This paper aimed to review findings from published studies about the appropriateness of eye care delivery, using existing published evidence and/or experts' practice and to describe the methods used to measure appropriateness of eye care.

Methods: A systematic search was conducted using Medline, Embase and CINAHL (2006 to September 2016). Studies reporting the processes of eye care delivery against existing published evidence and/or experts' practice were selected. Data was extracted from published reports and the methodological quality using a modified critical appraisal tool. The primary outcomes were percentage of appropriateness of eye care delivery. This study was registered with PROSPERO, reference CRD42016049974.

Results: Fifty-seven studies were included. Most studies assessed glaucoma and diabetic retinopathy and the overall methodological quality for most studies was moderate. The ranges of appropriateness of care delivery were 2-100% for glaucoma, 0-100% for diabetic retinopathy and 0-100% for other miscellaneous conditions. Published studies assessed a single ocular condition, a sample from a single centre or a single domain of care, but no study has attempted to measure the overall appropriateness of eye care delivery.

Conclusions: These findings indicated a wide range of appropriateness of eye care delivery, for glaucoma and diabetic eye care. Future research would benefit from a comprehensive approach where appropriateness of eye care is measured across multiple conditions with a single methodology, to guide priorities within eye care delivery and monitor quality improvement initiatives.
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http://dx.doi.org/10.1186/s12913-019-4493-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731572PMC
September 2019

Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis.

BMJ Support Palliat Care 2019 Aug 28. Epub 2019 Aug 28.

Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK

Objectives: Advance care planning (ACP) is essential for patient-centred care in the last phase of life. There is little evidence available on the safety of ACP. This study characterises and explores patient safety incidents arising from ACP processes in the last phase of life.

Methods: The National Reporting and Learning System collates patient safety incident reports across England and Wales. We performed a keyword search and manual review to identify relevant reports, April 2005-December 2015. Mixed-methods, combining structured data coding, exploratory and thematic analyses were undertaken to describe incidents, underlying causes and outcomes, and identify areas for improvement.

Results: We identified 70 reports in which ACP caused a patient safety incident across three error categories: (1) ACP not completed despite being appropriate (23%, n=16). (2) ACP completed but not accessible or miscommunicated between professionals (40%, n=28). (3) ACP completed and accessible but not followed (37%, n=26). Themes included staff lacking the knowledge, confidence, competence or belief in trustworthiness of prior documentation to create or enact ACP. Adverse outcomes included cardiopulmonary resuscitation attempts contrary to ACP, other inappropriate treatment and/or transfer or admission.

Conclusion: This national analysis identifies priority concerns and questions whether it is possible to develop strong system interventions to ensure safety and quality in ACP without significant improvement in human-dependent issues in social programmes such as ACP. Human-dependent issues (ie, varying patient, carer and professional understanding, and confidence in enacting prior ACP when required) should be explored in local contexts alongside systems development for ACP documentation.
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http://dx.doi.org/10.1136/bmjspcare-2019-001824DOI Listing
August 2019